All established patients of Khan Psychiatry are to have a card on file.
Unfortunately, at this time we do NOT accept American Express.
I understand that payment is due at the time services are rendered.
I understand that I may request a payment plan if I am unable to pay my balance in full at the time the service is rendered because: (1) I am a private pay patient; or (2) I have insurance, and I am subject to a deductible and/or co-insurance amount that I cannot afford to pay in full.
I understand that I must request a payment plan with Khan Psychiatry. I understand that half of my balance for the services rendered will be due at that time, and the remaining balance can be split into two (2) payments, with the first payment being due two (2) weeks later and the final payment two (2) weeks after that.
I understand that I will be charged a Late Cancellation fee of $75 for failing to call and cancel at least 24 hours prior to my scheduled appointment. If I am experiencing an emergency, I will provide as much notice as possible to avoid being charged the Late Cancellation fee; and in those instances, a decision will be made on a case-by-case basis while taking into account my history of late cancellations.
I understand that I will be charged a No Show fee of $150 for failing to call and failing to show for my scheduled appointment.
I understand that Late Cancellation and No Show fees will be automatically charged to my card on file. I understand that if this card is declined for a Late Cancellation or No Show fee, a second attempt will be made the following business day. If it is declined again,Khan Psychiatry will not allow me to schedule an appointment nor provide medication refills until I fulfill this financial responsibility. If payment for these fees is not received within 30 calendar days, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that these fees are not billable to insurance.
I understand that if I late-cancel, miss or no show, for whatever reason, to more than 3 appointments in one calendar year, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that my card on file will also be used for payment of services (co-payment, deductibles, and fees) that are due at the time services are rendered.
I understand that if I wish to utilize another form of payment, I must notify Khan Psychiatry immediately before or after my services were rendered.
I understand that if I have an active payment plan [for an outstanding balance] with Khan Psychiatry, this card will automatically be charged on the agreed upon dates. For payment plans, I understand that if my card is declined, a second attempt will be made the following business day. If it is declined again, and I do not reach out to the clinic to let them know that I am experiencing a financial hardship or that I need to re-work my payment plan, Khan Psychiatry will not allow me to schedule an appointment nor provide medication refills until I fulfill this financial responsibility. I understand that account payment, in full, will be due within 30 calendar days and I will no longer be eligible for any future payment plans. If payment in full is not received within 30 calendar days, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that Financial Hardships will be taken into account on a case-by-case basis.